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Full text of "United States Navy Medical News Letter Vol. 32 No. 4, 22 August 1958"

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UNITED STATES NAVY I V 

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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon. General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 32 



Friday, 22 August 1958 



No. 4 



TABLE OF CONTENTS 

Motor Vehicle Accidents - 1957 2 

The ECHO Viruses 5 

Recurrence of Nevi after Incomplete Removal 7 

Urethral Diverticula 9 

Chronic Pleural Empyema 11 

Treatment of Tuberculosis Today . 13 

Oral Treatment of Diabete s 16 

Voluntary Retirement . 17 

IN MEMORIAM 18 

From the Note Book 18 

Applications for Training in Civilian Institutions 20 

Symposium on Scintiscanning 21 

Course in Occupational Medicine 21 

Postgraduate Courses for Naval Medical Officers 22 

Board Certifications - Inactive Reserve Officers 23 

Recent Research Reports 24 

DENTAL SECTION 

FY 1958 . . 




Anniversary Greetings 26 Navy Dental Care 

RESERVE SECTION 

Reserve Medical Senninar 27 Correspondence Courses . . . . 

Catalog of Correspondence Courses 29 

AVIATION MEDICINE SECTION 

Aeronautical Adaptability 29 Occupational Health Hazards . 

Aircraft Accident Reporting. ... 32 Courses in Aviation Medicine 

Naval Aviator - Flight Surgeon . 33 "G" and "U" 

Hypoxia - Hyperventilation or CO^? ....... 39 



27 



28 



33 
37 
38 



Medical News Letter, Vol. 32, No. 4 



Motor Vehicle Accidents - 1957 

Every 76 minutes during 1957, on the average, a meraber of the Navy 
or Marine Corps was admitted to a medical facility for treatment of injuries 
received in a motor -vehicle accident. Every 15 hours, a naval serviceman 
was killed or died from similar injuries, and each day, 853 motor -vehicle 
accident victims were on the sick list. At one time, "going to sea" was 
considered a rather hazardous occupation, but the dangers pertaining to the 
sea are small as comipared with the present-day hazards of "going on the 
road. " Road traffic has become one of the most acute social, economic, 
and medical problems of the age. 

Although the statistics on motor -vehicle accidents for Navy and Marine 
Corps personnel were still alarmingly high in 1957, the over all picture was 
more favorable than in the preceding year. As compared with the 1956 rates 
for motor -vehicle injuries, the admission rate was down 11%, the noneffec- 
tive rate dropped 4%, and the death rate decreased by 9%. 

There were 6943 persons admitted to the sicklist in 1957 for injuries 
caused by motor vehicle accidents, resulting in an admission rate of 790 
per 100,000 average strength. Admission rates by naval district ranged 
from a low of 628 per 100, 000 for personnel stationed in the 3rd Naval Dis- 
trict to a high of 1321 per 100, 000 in the 13th Naval District. 

Traffic accidents — those occurring on public roads, streets, and high- 
ways — accounted for 6840 (98,5%) of the admissions due to motor- vehicle 
injuries. Nontraffic accidents — those happening on parking lots, private 
driveways, within boundaries of military bases, et cetera — chalked up a 
total of 103 (1. 5%) of the 1957 admissions. 

More admissions for motor- vehicle accidents occurred on 1 January 
than on any other day of the year. This was true for both 1956 and 1957. 
On 1 January 1956, there were 71 admissions and on this date in 1957, 
the number recorded was 49. The day which had the second highest num- 
ber of admiissions in 1957 was 16 February with 48 admissions. For the 
entire year, more accidents occurred on Saturday than any other day of 
the week. Almost one-fifth (1300) of the total admissions were on Satur- 
day. Motor-vehicle accidents were not consistently concentrated in any 
one month. 

The most frequent cause of these accidents involved running off the 
roadway without an antecedent collision, causing 31% of the accident admis- 
sions and 33% of the deaths. This would indicate the driver was at fault — 
perhaps driving too fast, being too sleepy from a long driving spell, or 
failing to skip the last drink which was "one for the road. " The second 
leading cause was collision with another motor vehicle which was respon- 
sible for 28% of the admissions and another 33% of the fataJities. 

A recent research study at the Marine Corps Base, Camp Lejeune, 
N. C. , brought out the fact that the average accident driver was a base- 
re siding, young, unnnarried, noncareer man of the lower enlisted grades 



Medical News Letter, Vol. 32, No. 4 



in an off-duty status. The accident happened most frequently while he was 
driving a recently purchased, used vehicle within 20 miles of the base late 
at night or early in the morning. Admission rates for enlisted personnel 
were more than three times those for officers. 

Distribution of patients by age and length of service is shown. The 
extremely high admission rates of the Navy and Marine Corps groups aged 
20-24 indicate that accidents at this age occur more often than warranted by 
their relative strength. The groups reporting the second highest adnaission 
rates were the same as last year — "under age 20" for the Navy and 25-29 
for the Marine Corps. Navy personnel aged "45 and over" showed the great- 
est improvement over their 1956 record of accidents. They not only had the 
lowest admission rate for 1957, but also reported the greatest percentage 
decrease from 1956 — almost a 50% drop. As in 1956, the Marine Corps 
personnel aged 20-24 had the least favorable motor- vehicle -accident exper- 
ience in 1957, but at the same time reported a drop of 23% in admission rate. 
The median length of service for all motor-vehicle-injury cases was 3 years. 

Ninety percent of the motor -vehicle admissions in 1957 were due to 
accidents occurring while the personnel involved were on leave or liberty. 
During 1955 and 1956, this proportion was 88%, Recruits report the lowest 
admission rates — undoubtedly due to curtailment of leave during recruit 
training. 

Twelve percent of Navy traffic injury admissions involved motorcycle 
riders, while for the Marine Corps, the comparable proportion was only 6%. 
The types of vehicles caus-ing relatively more accidents anmong members of 
the Marine Corps than the Navy are military passenger-carrying vehicles, 
trucks or buses, and tanks or tractors. They contributed 10% of the Marine 
Corps' traffic -accident admissions in contrast to 4% of the Navy's. 

A third of the Navy and Marine Corps motor-vehicle-accident cases 
in 1957 were admitted to the sicklist with the diagnosis of "fracture. " 
"Wound, incised and lacerated" and "abrasion" figures in about another third 
of the injuries. The diagnosis "injuries, multiple, extreme, " which gener- 
ally describes dead-on-arrival cases, was the diagnosis applicable to over 
half of the fatal cases. 

Severity of accidental injuries can be judged partially by the extent of 
hospitalization required for recovery. About one-third of the 7157 motor- 
vehicle injury cases leaving the sicklist in 1957 had required a month or 
more of hospitalization. Of these, 912 cases had 30-59 sick days, 1509 
cases had 60-364 sick days, and 68 naval servicement had been either hos- 
pitalized or on sick leave for a year or more. 

As to the matter of total hospitalization, nnotor- vehicle -injury cases 
accumulated 311,423 days on the sicklist in 1957, or an average of 45 days 
per new case as compared with 42 days in 1956. 

Pedestrians injured in traffic and nontraffic mishaps averaged more 
than 70 days on the sicklist. Motorcycle accidents also caused long periods 
of hospitalization — an average of 52 days. 



Medical News Letter, Vol. 32, No. 4 



The most tragic part of the motor -vehicle -accident picture, of course, 
was the 570 servicemen who lost their lives. The death rate of 65 per 
100,000 average strength was lower than the comparable rate of 72 in 1956. 
Although fewer were killed in 1957, there were also fewer admissions and 
the fatality ratio (8.2 deaths per 100 admissions) was a little higher than in 
1956 (8. 1). Four out of five fatal cases had zero days on the sick list — most 
of these being "dead on arrival" Another 11% survived less than 5 days. 
However, 5 cases which terminated in death were on the sicklist from 35 to 
150 days. Off-duty accidents were responsible for 92% of the deaths. A 
short weekend liberty pass is a temptation to drive far and fast to be with 
distant family and friends. Too often, it turns out to be a pass to eternity. 
Long after the crashing sound of the auto collision and the wail of the 
ambulance have died away, there remain the suffering of the victim, the 
anxiety of loved ones, long and expensive months of hospitalization, and too 
often, physical disabilities to be borne for the remainder of life. 

After hospitalization, about 6000 patients were able to return to duty. 
However, even after extensive hospitalization, all accident patients do not 
recover sufficiently for a duty status. Of those injured during 1957, approx- 
imately 370 were invalided from the service because of accident injuries or 
sequelae. 

The servicemen killed and invalided from service because of motor- 
vehicle -accidents spell out a great tragedy to their families and friends. 
This tragic loss of lives and manpower is also a tremendous expense to the 
Navy and Governnnent in terms of lost training investment, burial costs, 
and survivor and retirement benefits. How much the naval services lose in 
terms of training investments can be nnore fully realized from the statement 
that the total years in service accumulated by those killed in 1957 were equi- 
valent to almost 2-1/2 centuries of time, or full 30-year naval careers of 
approximately 800 men. In terms of monetary figures, it is estimated that 
the 1957 motor-vehicle accidents represent a cost of 25. 6 million dollars 
to the Government. 

The traffic accident problem is not confined to military personnel 
alone. From the entire population of the United States, over 38, 000 motor- 
vehicle deaths and about 1, 350, 000 injuries occurred during 1957. Many 
groups and organizations are concerning themselves with the various factors 
involved in these accidents. Findings of statistical research teams show 
that collaboration among engineers, manufacturers, and doctors is needed 
to accomplish effective preventive measures against this growing peril. 
Until recently, studies were directed mainly toward ascertaining the causes 
of accidents. Now, research programs are turning their attention to the car 
and the driver. 

The Navy and Marine Corps are placing increased emphasis on various 
safety programs to prevent motor-vehicle accidents. New research programs 
are giving added attention to the safety factors in vehicular design and to the 



Medical News Letter, Vol, 32, No. 4 



physical and psychological characteristics of vehicle operators, (Motor- 
Vehicle Accidents - 1957: Statistics of Navy Medicine, 14: 5-13, July 1958) 

Rear Admiral B. W. Hogan MC USN, the Surgeon General, in a foreword 
to this article stated "If we are to make significant advances in coping with 
this problem, we must concentrate further effort toward understanding the 
psychological as well as the physical factors involved. For the Navy, this 
means greater emphasis on dynamic and effective programs in safety and 
applied research. For the individual naval man, it means taking heed of 
his responsibilities when he gets "behind the wheel. " It may seem trite, 
but still it is true, that the observance of the rules of safety and decent 
conduct can mean "The Life You Save May Be Your Own, " 

:>): ^ ij: :{: 9}: ^ 

The ECHO Viruses 



A recent estinnate places the number of new human viruses which have 
been discovered since 1948 at 70. The dilennnna which this appalling number 
of newcomers presents to students of infectious disease involves many prob- 
lems in virology as well as the innportant question - What role do these 
agents play in human disease? As for the new and growing ECHO group of 
enteric viruses, now numbering 20, an encouraging beginning has been made; 
It has been possible to evaluate at least some of these agents in terms of 
their disease -producing potential and to place them with respect to other 
viral enteric pathogens, namely, the Coxsackie and poliovirus groups. In 
fact, the 20 ECHO, 24 Coxsackie, and 3 polioviruses have recently been 
joined together to form the Enterovirus group. The reasons for this 
grouping are the similarities between the three families of viruses: 
They are all common inhabitants of the human intestinal tract; they have 
epidemiological features in common, and they produce a range of human 
infection from completely inapparent or' minor febrile illnesses to 
aseptic meningitis and, in the case of polioviruses at least, to myelitis 
with paralysis. 

ECHO viruses (whose name stands for enteric cytopathogenic human 
orphan) are the newest members of the enterovirus group. Their name is 
descriptive of their history and character: They have been isolated frequent- 
ly from human excreta, their discovery actually being a byproduct of tissue- 
culture tests for the presence of polioviruses in fecal samples; they cause 
specific cytopathic changes in certain primate tissue culture cells, but (with 
some exceptions) do not produce disease in any of the usual laboratory 
animals, and they are— or were — largely "orphans" from the standpoint 
of their place as pathogens because their relationship to disease was in the 
beginning quite unknown and is only gradually becoming apparent. 



Medical News Letter, Vol. 32, No. 4 



Although the exact mode of spread of ECHO viruses is not known, 
the evidence suggests that human association is the most innportant means. 
The pattern of infection in families is similar to that associated with Cox- 
sackie and polioviruses and it is probable that similar mechanisms are 
involved in infection with all three members of the enterovirus group, the 
oropharynx being the portal of entry; the intestinal tract, the primary site 
of attack; and the feces, the chief means of excretion. Seasonal distribu- 
tion of ECHO viruses is another characteristic shared with Coxsackie and 
polioviruses. 

With such wide distribution of ECHO viruses, the question arose early 
as to whether these agents might not be normal or pelrnanent inhabitants 
of the intestinal tract, rather like nonpathogenic bacteria, such as Escher- 
ichia coli. That this is not the case is indicated by the transience of the 
infection and carrier state, the large proportion of young children among 
carriers, the relative infrequency of carriage among adults, and the sea- 
sonal occurrence of the agents. 

The illnesses associated with enteroviruses are indicated in a Table, 
There are no distinguishing clinical features which indicate that in a given 
case the infection is due to a member of the ECHO group rather than one 
of the other enteroviruses, but certain characteristics are helpful in sug- 
gesting the possibility. One of these is the presence of rash. To date, 
rash has been noted in infections with ECHO virus Types 4, 6, 9, and 16, 
and there has been an associated enanthem with Types 9 and 16. In addition, 
an exanthem has occurred with certain Coxsackie A-9 infections and with 
infection associated with new strains not belonging to any of the 20 desig- 
nated ECHO types. Both aseptic meningitis and cases of mild febrile ill- 
ness have been associated with rash. 

Aside from rash, the illnesses associated with ECHO virus infections 
have not been significantly different from aseptic meningitis or mild non- 
specific febrile illnesses associated with other enteroviruses. Moderate 
fever, severe headache, and stiff neck and/or back have been the most 
prominent features in those with C.N. S. involvement. In certain outbreaks, 
severe muscle pain has occurred, and in one due to ECHO 9, relapses were 
reported as not uncommon. 

The occurrence of a biphasic course sinnilar to that found in polio- 
myelitis has been noted in several epidemics, but this does not seem to be 
as common a feature as in children with poliomyelitis, 40% or more of whom 
nnay show this feature. If any difference can be noted between the "minor 
illness" of first phase or abortive poliomyelitis and the febrile illnesses 
associated with ECHO viruses, it is one of degree: the "minor illness" or 
abortive poliomyelitis is usually a milder affair, most often only 24 hours 
in duration and less apt to be associated with headache and vomiting. 

ECHO viruses, a rapidly growing family of 20 recently discovered 
agents belonging to the enterovirus group, are common inhabitants of the 



Medical News Letter, Vol. 32, No. 4 



human intestinal tract, particularly in the summertime. In addition to 
inapparent infection, certain types may cause mild febrile illness, diarrheal 
syndromes, or aseptic meningitis, Some types have been associated with 
widespread epidemics in Europe and the United States. A rubella-like rash 
has been a prominent feature of epidemics due to Types 4, 9, and 16. Anti- 
genic diversity and clinical surprises have been the rule in the short history 
of ECHO viruses. There is reason to believe that these characteristics will 
continue and that the family will grow in nuaiber and complexity. (Horstmann, 
D. M. , The New ECHO Viruses and Their Role in Human Disease: Arch. 
Int. Med., 102: 155-160, July 1958) 

* jjt * * 4; * 

Recurrence of Nevi after Incomplete Removal 

Along with recent advances in the knowledge of pigment formation and 
of pigment-cell biology, there has been an increasing interest in the pig- 
mented mole or nevus. Because it is an extremely common lesion and 
clinically often disfiguring, many patients are seen who desire cosmetic 
removal of these moles. Much has been written about benign pigmented 
nevi, their pathology, relation to melanonna, and their treatment, but little 
has been published about treatnnent failures and recurrence. This article 
discusses various mechanisms by which benign nevi may recur after treat- 
ment, and evaluates the significance of such recurrence. 

Several nnethods of dealing with the common mole are described in the 
literature. These may be divided into two main types: deep excision which 
remioves the entire lesion and other methods which do not connpletely rennove 
it. Many dermatologists feel that nnalignancy in the common mole can be 
reliably ruled out with expert clinical examination and that such clinically 
benign lesions may be safely removed by use of electrocautery, electro- 
dessication, or by merely slicing off the protruding portion. 

After superficial removal of this type — which is used simply for cos- 
metic purposes — there nnust necessarily be a certain percentage of recur- 
rence. In one series, of 129 small pigmented lesions, 4 were excised be- 
cause of failure of previous treatment. In another series of 204 nevi, 2 had 
had prior unsuccessful removal. 

Two types of clinical appearance of these recurrences are described. 
The lesion nnay reappear as (1) an area of pigmentation, or (2) an elevation 
at the site of previous removal. Walton et al. state that pigmentation re- 
mained in about half of their series of l68 clinical moles which were re- 
moved by slicing and light electrodes sication, but that in only 1 case of their 
completed series of nnore than 100 lesions which were followed and rebiop- 
sied was there a definite recurrence of the lesion as a flat area of pigmen- 
tation. 



8 Medical News Letter, Vol. 32, No. 4 



When this present study was begun, there had been no systematic 
investigation of the mechanism and of the significance of these benign recur- 
rences. Gougerot, who observed nevi to recur in the scar of previously 
destroyed nevi, felt that this recurrence was due to seeding of the nevus 
cells during removal. This concept of the mechanism of recurrence con- 
tinues to be upheld in Europe where some believe that even biopsy of a 
pigmented lesion should not be attennpted until high doses of irradiation 
have been applied to prevent growth of any possibly seeded cells. 

Recently, Walton, Sage, and Farber made an excellent study of this 
problem. They sliced off the superficial portion of the mole and cauterized 
the rennaining denuded surface. The slice was examined nnicroscopically 
to determine the exact nature of the lesion. After varying periods of time, 
the treated site was rebiopsied and the specimen was compared with the 
earlier biopsy. They found that in no case was there any tendency toward 
malignant change in the lesion and that when there was a recurrence it 
resembled the original lesion. 

This study concerns 19 cases of recurrent pigmentation after cos- 
metic removal of a mole. The site of recurrence was excised for nnicro- 
scopic study. In the interpretation of histologic findings, the authors follow 
the generally accepted view that most nevi originate at the dermo-epidernnal 
junction fronn the nnelanocytes which are present normally, through their 
multiplication and transformation into nevus cells. They agree with those 
who accept the neural crest origin of nnelanocytes and do not believe that 
they are nnodified epidermal basal cells. They also agree that each nevus 
has a natural history beginning as a simple lentigo in which melanocytes 
accumulate at the dermoepidermal junction. These melanocytes form 
larger nests of nevus cells at this junction. Some or all of these nests may 
become detached from the epidermis and surrounded by mesodermal fibers 
of collagen, elastin, and reticulum. In the final mature stage of the nevus, 
all nests are in the dermis and none are left at the junction. 

According to these three stages of development, nevi are divided into 
junction, compound, and intradermal lesions on histologic examination. 
It must be realized, however, that these terras refer only to the prevalent 
localization of the cell nests. Most junction nevi show some intradermal 
nests and many mature, clinically quiescent nevi show some junctional 
nests. This latter finding increases in direct proportion to the number of 
sections examined from each individual nevus and it is likely that fewer 
intradermal nevi would be recognized if each lesion were examined in com- 
plete serial sections. 

The findings in 19 cases are summarized in a Table. Certain features 
are connmon to these cases. The original Ission is diagnosed as a common 
benign nnole and is incompletely remioved. After a varying period of time — 
usually a number of months — pigmentation recurs. The tunnor mass itself 
does rj-Ot regrow. 



Medical News Letter, Vol. 32, No. 4 



Nevus cells — especially early in their development — when they are 
junctional and active, are also found with the basal cells of the epidermis 
and with the follicular sheath of the hair. It is to be expected that any nevus 
cells present in such areas, such as in a compound nevus which is removed 
for cosmetic purposes, would be carried along with the regenerating epi- 
thelium over the denuded area. In some cases, they obviously multiply and 
form a new junctional nevus above the quiscent intradermal remnants of the 
old nevus. 

The question of the prognostic significance of this process then arises, 
whether this means activation of a quiescent nevus implying possible progres- 
sion to a malignant state. There is no evidence of such implication in either 
Walton's or the authors' material. Walton found that no junctional activity 
occurred in any nevus which did not show it in the original lesion. The two 
cases in the present series in which the original nevus was available for study 
support this view. In none of the cases was there evidence of the criteria 
upon which the diagnosis of malignancy in a cellular nevus rests. There 
were no mitoses, no cells of linusual size, and no reactive inflammatory 
infiltrate. 

Instead, it seems that the nevus relives an early part of its natural 
history. Just as in children, the finding of a junction nevus is the connmon 
expected occurrence and does not imply malignant development, so here in 
a young epidermis, nevus cells form junctional nests. From the experience 
of a great number of dermatologists polled in a recent survey, it may be pre- 
sumed that this process eventually would have reached a stage of balance and 
quiescence. 

The authors' experience in these and other cases and with Walton's 
study suggest that it is preferable to microscopically examine at least the 
superficial portion of nevi removed for cosmetic purposes. Such examination 
would allay anxiety of the patient and enable recognition of the extremely rare 
nevus that shows histologic evidence of malignancy in spite of clinical quies- 
cence as determined by an experienced dermatologist. (Schoenfeld, R. J. , 
Pinkus, H. , The Recurrence of Nevi after Incomplete Removal: Arch. Dermat. , 
78: 30-34, July 1958) 

sic rfC A jSc rfg IjC 

Urethral Diverticula 

Increasing experience with the diagnosis and management of subure- 
thral diverticula on the gynecological service of the Johns Hopkins Hospital 
has led to the accumulation of a series of 121 cases of a lesion once con- 
sidered rare. 

There has been much discussion as to whether urethral diverticula 
constitute a congenital or an acquired lesion. One case in this group is 



10 Medical News Letter, Vol. 32, No, 4 



undoubtedly congenital in origin, the diverticulum representing the point 
of insertion of an ectopic ureter. Some authors have suggested that the 
trauma of childbirth plays an etiologic role. Analysis of the parity in this 
series does not support such a conclusion. 

Some indirect support of the acquired nature of the majority of diver- 
ticula is obtained by exan:iination of the age at which symptoms first appeared 
in patients later found to have the lesion. Only two of the totel series of 121 
cases were symptomatic prior to the age of 15, while the great bulk of 
patients developed symptomatology between the ages of 20 and 40 years. One 
might reasonably expect an earlier expression of the disease, were it pre- 
dominantly of congenital origin. 

On the basis of the comparatively late development of symptomatology, 
as well as the lag between the development of symptomatology and the appear. 
ance of a clinical lesion, the authors are inclined to agree with Routh that 
suburethral diverticula largely represent an acquired lesion of infectious 
etiology. 

The most common complaints presented by patients in this series were 
those of frequency (100 patients) and dysuria (76 patients). While the major- 
ity of these women gave a history of recurrent attacks of cystitis, the symp- 
tomatology associated with suburethral diverticula is truly protean. Indeed, 
nine patients denied any complaints whatsoever referable to the urinary sys- 
tem, a sizable diverticulum constituting an incidental physical finding. 

With regard to the symptoms of terminal dysuria (16 cases) and sense 
of incomplete voiding (32 cases), it is only within the comparatively recent 
past that a significant proportion of the clinical histories contain definite 
statements as to the presence or absence of these complaints, so that the 
actual incidence may be somewhat higher than here indicated. 

Chronicity of symptomatology is by no means a uniform finding, al- 
though suburethral diverticulum should certainly be ruled out in any patient 
with chronic or recurrent unexplained urinary complaints. Seventeen patients 
reported no attacks of cystitis in the year immediately prior to the diagnosis, 
while an additional 20 cases reported only one attack of cystitis in the pre- 
ceding year, so that 31% of the total series certainly did not present with 
an unremittingly symptomatic lesion. Conversely, 24 patients, or 20%, of 
the total series, reported experiencing three or more attacks of cystitis in 
the year preceding the diagnosis of suburethral diverticulum. Prolonged 
periods of spontaneous remission of symptoms were not uncommon. 

The most important single diagnostic instrument for the discovery of 
suburethral diverticula is a high index of suspicion. The finding of a sub- 
urethral mass and the expression of pus from the external urethral meatus 
on routine stripping of the urethra during the course of pelvic examination, 
remain the classic diagnostic maneuvers. 

While cystoscopy remains an invaluable tool in the diagnosis and man- 
agement of urethral diverticula, it appears to be more fallible as a screening 



Medical News Letter, Vol. 32, No. 4 11 



technique than urethrography. Seventy -four patients with proven diver- 
ticula had the benefit of water cystoscopy. In 12 of these cases, a urethral 
orifice was never visualized cystoscopically. An additional 16 patients 
underwent four or more unproductive cystoscopies prior to the discovery 
of the diverticulum. 

The authors believe that every case should have the benefit of urethro- 
graphy prior to surgery. The existence of a compound or multilocular diver- 
ticulum cannot be predicted by reliance on cystoscopy alone. Furthermore, 
while endoscopic inspection of the urethra may disclose the presence of one 
diverticular orifice, other orifices may be present concurrently. Twenty- 
eight patients in this series were found to have either multiple or com- 
pound diverticula. 

There is general agreement in the literature that surgical excision of 
the diverticulum, when feasible, is the procedure of choice. (Davis, H, J. , 
Telinde, R. W , Urethral Diverticula, An Assay of 121 Cases: J. Urol. , 
8£: 34-38, July 1958) 

jj: if: :{: ^ ::}: ^ 

Chronic Pleural Empyema 

In recent years, the prognosis of chronic pleural empyema has im- 
proved to a remarkable extent. Although much of this improvement is 
attributable to the use of potent antibacterial agents, other factors undoubt- 
edly have contributed to these results. In attempting to evaluate some of 
these factors, one discovers that it is difficult to gain an adequate perspec- 
tive from recent reports as they are generally limited to scope and occas- 
sionally are controversial. As it seemed likely that the experience in a hos- 
pital for thoracic disease might provide such information, it was decided to 
review the cases of chronic empyema treated surgically at the Ray Brook 
State Tuberculosis Hospital, N. Y. , between January 1950 and October 1957. 

To provide a basis for comparison, both tuberculous and pyogenic 
empyemas were included in this study. Several sterile empyemas were also 
included. Patients treated merely by thoracentesis or surgical drainage were 
excluded. Thus, there were available for study 45 patients treated by 56 
definitive surgical procedures. Thirty-nine patients had pulmonary or pleural 
tuberculosis at one time or another. The remaining 6 patients had, in addi- 
tion to empyema, the following diseases: cystic disease of the Ivmg, 1; 
bronchogenic carcinoma, 1; spontaneous pneumothorax, 1; pyogenic pneu- 
monia, 2; pulmonary disease of undetermined etiology, 1. The empyemas 
followed thoracotomy in 29 instances; 9 complicated therapeutic or spon- 
taneous pneumothorax; 10 were primary. When first bacteriologic studies 
were performed at Ray Brook, 23 empyemas yielded tubercle bacilli, 8 
yielded mixed tuberculous and pyogenic organisms, 11 yielded pyogenic 



12 Medical News Letter, Vol. 32, No. 4 



organisms, and 3 yielded purulent material sterile on culture. The pyogenic 
infections usually included staphylococci. By the time surgery was under- 
taken, the number of tuberculous and mixed tuberculous and pyogenic infec- 
tions had decreased to 16 and 7, respectively; the number of pyogenic 
infections and sterile pleural spaces had increased to 13 and 9, respectively. 

It is interesting to note that, of the 7 patients with mixed tuberculous 
and pyogenic empyema at the first bacteriologic examination, 6 had already 
been subjected to thoracotomy and 1 had received a recent bronchogram — 
a possible source of contamination of the pleural cavity. Of 14 patients 
with pure pyogenic empyemas at the first bacteriologic examination, 11 had 
been submitted to previous chest surgery. These findings are especially 
interesting because the authors observed pleural spaces communicating with 
the bronchial tree for prolonged periods without detecting evidence of infec- 
tion. Therefore, it would appear that secondary pyogenic infection is fre- 
quently iatrogenic — a belief which is certainly not new. 

From a Table, it may be inferred that tuberculous empyemas frequent- 
ly can be rendered sterile by drug therapy alone. Almost all will respond 
favorably to drug therapy combined with adequate surgery. On the other 
hand, surgery without adequate anti tuberculous drug therapy is not often 
successful. 

The prognosis for mixed tuberculous and pyogenic empyema is no 
longer as poor as it was prior to the introduction of antituberculous drug 
therapy. The presence of secondary pyogenic infection does not seem to 
affect the response of the tuberculous infection to antituberculous drug therapy. 

Surgery was performed in 56 instances. To be successful, definitive 
surgery should obliterate the pleural space. A persistent pleural space — 
even if sterile — is a potential invitation to infection. Standard and plombage 
thoracoplasty are of limited value and are useful only when the walls of the 
empyema are not very rigid. Plombage thoracoplasty is occasionally com- 
plicated by infection in the subcostal space. On the other hand, the Grow 
modification of the Schede procedure can be used with little fear of deformity 
and with excellent results; being confined to the diseased area, it is well tol- 
erated by the poor-risk patient. It can be performed in stage, or repeated 
should the first procedure fail to achieve the expected result. It is important 
to remove foreign bodies, such as surgical silk or calcium deposits, as these 
may be a source of chronicity. A simple method of removing calcium is cur- 
ettage. The wound may be sutured almost completely at the time of surgery. 
Adequate drainage should be maintained with a soft rubber tube until the em- 
pyema space has been obliterated from the depths outward. A pressure dres- 
sing for several weeks will foster early obliteration of the space. 

Decortication has proved most useful in expanding lungs which contain 
little disease and where the empyemas have been of relatively short duration 
or small size. Appreciable pulmonary fibrosis is a well-known cause of 
poor postoperative re -expansion. Longstanding empyema may involve the 



Medical News Letter, Vol. 32, No. 4 13 



underlying lung so as to produce a similar effect and, if the empyema in- 
volves a large proportion of the lung surface, postoperative re -expansion 
of the lung may be poor. On the other hand, if the empyema involves only 
a small portion of the lung surface, the remaining lung will often expand 
appreciably if it is completely freed, including the fissures. A poorly ex- 
pansile lung may be useful as a space filler. For this reason, resection of 
such a lung is rarely performed with decortication except for indications 
applicable in the absence of empyema. Although parietal decortication 
would seem generally desirable, it does not appear necessary to effect a 
cure of empyema. Parietal pleura may be allowed to remain if one wishes 
to minimize blood loss. Occasionally, in these instances, pleural symphy- 
sis may be delayed, but this does not seem serious. Pulmonary expansion 
following decortication appears to have no ill effects upon pulmonary tuber- 
culosis, provided adequate antituberculous therapy is administered. 

This review of almost 7 years' experience with chronic empyema 
reveals that with proper treatment the prognosis is excellent regardless of 
the type of infection. (Pecora, D. V, , The Surgical Treatment of Chronic 
Pleural Empyema: J. Thoracic Surg., 36: 9Z-101, July 1958) 

^ jIc * * ^ ^e 

Treatment of Tuberculosis Today 

This article summarizes observations in over five hundred consecu- 
tive patients with proved tuberculosis admitted for treatment to the Central 
Washington Tuberculosis Hospital between June 1, 195Z and December 31, 
1956. Antituberculous drug therapy had not been given these patients before 
admission here; some had had previous collapse therapy or bedrest in other 
institutions. The cases include all types of tuberculosis — primary, reinfec- 
tion, pulmonary, and extrapulmonary — and all age groups. The diagnosis 
was proved either by positive cultures, positive pathological findings, or 
both. All patients had been given the three most effective and least toxic 
antituberculous drugs, streptomycin, para-aminosalicylic acid and ison- 
iazid, along with early surgery when indicated. The regimen included 
modified bedrest with full lavatory privileges for all patients and they were 
permitted to go to the cafeteria as soon as physically able after admission. 
Upon discharge, all patients returned to their former occupations regard- 
less of physical activity involved. 

The patients were hospitalized for an average of 212 days. One h\in- 
dred and forty-two patients were treated surgically and 188 patients were. 
treated medically. There was a minimum follow-up of over 24 months. 

There are five characteristics of tuberculosis which make it a par- 
ticularly difficult disease to treat: First is the tendency of tubercle bacilli 
to become resistant to any known antibiotic when they can continue to multiply 



14 Medical News Letter, Vol. 32, No. 4 



in the presence of small concentrations of the drug; second is the tendency 
of blood vessels in the diseased area to become obliterated v/hich, in turn, 
further decreases the concentration of drugs where they are most needed; 
third is the tendency of the disease to produce destruction of tissue (casea- 
tion) which then has no blood supply and the drugs cannot diffuse into it in 
sufficient quantity to be bactericidal; fourth is the presence of viable tuber- 
cle bacilli inside macrophages so that an antibiotic, such as streptomycin 
which does not penetrate the cell membrane, is not effective; and fifth is 
the tendency to obstruct the normal drainage pathways, for example, in 
bronchial stenosis or uretero stenosis. 

An organized treatment program is described for all types of tuber- 
ulosis, using streptomycin, para-aminosalicylic acid, and isoniazid, togeth- 
er with early surgery when indicated. 

The three -drug combination resulted in negative sputum and gastric 
cultures in 84% of all patients by the end of 4 months. In those whose cul- 
tures remained positive, antibiotic -resistant organisms developed. 

Hesectional surgery is indicated in pulmonary tuberculosis for the 
following reasons: (1) to convert to negative the cultures of patients positive 
after 3 months of drug therapy; (2) to remove the types of infected tissues 
likely to cause reactivation of disease or which have already caused reac- 
tivation, namely caseous lesions 2 cm. or more in diameter, cavity, and 
advanced bronchial disease including stenosis, bronchiectasis, and tuber- 
culous bronchitis; and (3) decortication for restoration of pulnnonary func- 
tion after extensive pleural change from pneumothorax or pleural effusion. 

Tubercle bacilli resistant to a major drug (streptomycin or isoniazid) 
are found in patients on the first admission even though they have never 
received the drug and could not have contracted their disease from someone 
who had received the drug. 

In patients with persistently positive cultures for 6 months or longer, 
organisms develop which are resistant to the major drugs, and when resected, 
have a high incidence of complications including bronchopleural fistulas, pos- 
itive cultures after resection, and reactivation after discharge. 

Even though drug therapy may convert gastric and sputum cultures to 
negative, the infected lesion is not necessarily sterilized because in a sig- 
nificant nunnber of these patients, a positive smear or culture is obtained 
from resected specimens or the disease is reactivated later. 

Drug therapy is merely a tool in the treatment of tuberculosis, effec- 
tive for a limited time, and if not properly used, the patient will have lost 
the opportunity for successful resection. 

Reactivation is due to the presence of virulent, viable tubercle bacilli 
in certain types of infected tissue into which the drugs cannot penetrate. The 
extent of disease is a factor in reactivation because the more extensive the 
disease, the greater the likelihood of serious pathological change being 
present; thus, minimal disease responds well to drugs only whereas surgical 



Medical News Letter, Vol. 32, No. 4 15 



patients do better than medical patients with moderately and far advanced 
disease because the source of reactivation has been removed. 

With routine anteroposterior tomographs and right angle and fore- 
oblique telescopes for use in bronchoscopy, it is possible to demonstrate 
most types of tissue involvement which are likely to cause reactivation. 
Caseous disease is the most common pathological change found in 
patients in whom reactivation occurs; therefore, it is as dangerous a lesion 
as open cavitation when it has a bronchial connection which is manifest by 
positive cultures before drug therapy is started. 

Endobronchial disease is the second most common pathological change 
found in patients in whom reactivation occurs. This applies both to tuber- 
culous bronchitis and to bronchial stenosis of the segmental bronchi. 

The purpose of follow-up is to detect reactivation of disease before 
there is progression. Therefore, gastric cultures should be obtained about 
6 months after stopping combined drug therapy. Patients may have positive 
gastric cultures a year or more before there is x-ray evidence of new disease 
or before they will admit to bringing up sputum. 

While certain groups of patients have a higher incidence of toxic reac- 
tions to the various drugs (for example, the P, A. S. reactions in patients 
with emphysema, streptomycin, and dihydrostreptomycin reactions in patients 
with renal tuberculosis, and isoniazid reactions in patients with epilepsy), 
these reactions can, and do, occur in other patients, even in children. These 
reactions may be serious and can be fatal if not recognized. All but the "toxic 
nephritis" from dihydrostreptomycin occur within the first 50 days of treat- 
ment. 

The program described has reduced the mean period of hospitaliza- 
tion to 139 days for the 109 patients admitted in 1956. It has decreased the 
cost of hospitalization by 50%. It has eliminated the need both for occupa- 
tional therapy and rehabilitation because the patients are returned to their 
former occupations upon discharge regardless of the physical activity in- 
volved in their work. 

Approximately 3% of all patients admitted to the hospital died of tuber- 
culosis, chiefly children of 5 years or less with tuberculous meningitis. 
Another 3% died during hospitalization of associated disease, mainly in the 
age group of 55 years and over. About 2% remained chronic cases. Thus, 
a satisfactory result was obtained in 92% of all proved cases of tuberculosis. 
Over the 5-year period included in this group, the nunnber of new cases 
of tuberculosis found and the extent of the disease did not decrease. This 
program has received excellent patient cooperation as shown by the high 
rate of acceptance of the recommendation of resection (36% of all admissions) 
and the few irregular discharges (8%), Drug treatment of nonhospitalized 
patients with tuberculosis falls far short in every respect of what can be 
achieved with immediate hospital care. (Allen, A. R. , Treatment of Tuber- 
culosis Today - A Five-Year Report: Am. J. Med. ,XXV: 75-87, July 1958) 



16 Medical News Letter, Vol. 32, No. 4 



Oral Treatment of Diabetes 

In the treatment of diabetes, insulin is irreplaceable; no satisfactory- 
substitute has yet been discovered. However, the need for parenteral admin- 
istration of insulin has stimulated the search for substances which will lower 
the blood sugar when given by mouth. Recently, certain sulphonylureas 
(notably carbutamide and tolbutamide) have been shown to do this. Unfor- 
tunately, sulphonylureas are effective in mild diabetes only; this is in accord 
with the experimental finding that some functioning pancreatic islet tissue 
is necessary for them to exert full action. 

Ungar et al, in 1957, investigated a series of compounds of different 
structure belonging to the diguanide group and found that one of them, phen- 
ethyldiguanide or N-beta-phenethylformamidinyl iminourea (D. B. I. ) was 
able to produce hypoglycemia even in eviscerated or alloxan-diabetic animials. 
Later, workers confirmed that this substance can lower the blood sugar in the 
absence of insulin. 

This article assesses the effectiveness of D.B.I, as a hypoglycemic 
agent in diabetes of all grades of severity, gauges its side effects, and com- 
pares its mode of action with that of insulin and tolbutan:iide. 

D. B. I. was demonstrated to be an effective hypoglycemic agent in 
mild and moderate diabetes. At a dosage of 50 mg. three times a day, it 
reduced the blood sugar to normal levels, in some cases, even in the pres- 
ence of ketonuria, and in some patients who failed to respond to tolbutamide. 
Unfortunately, its administration was accompanied by gastrointestinal dis- 
orders in no less than two-thirds of the diabetics in whom it was used. 
Nausea, abdominal discomfort, vomiting and diarrhea were severe enough 
to necessitate withdrawal of the drug in these patients. Symptoms usually 
quickly subsided on cessation of treatment, but vomiting is a particularly 
unwelcome symptom in diabetics. No toxic effects were observed in the 
blood or in the liver of patients so far treated, but the period of observa- 
tion has not extended for more than a few months. 

Experimental evidence suggests that the drug has tvi'O main modes of 
action: first, it decreases the output of glucose from the liver by depres- 
sing gluconeogenesis and, second, it increases glucose utilization by the 
tissues. The authors' results support the view that D. B.I. does not act 
like insulin. In contrast to insulin, D. B. I. was quite unable to relieve 
acidosis in severe diabetics, and normoglycemia could be attained in only 
about one -third of diabetics to whom the drug was given. 

The lack of effect of D, B.I. on the amino-acid nitrogen levels in the 
present trial indicates again that D. B. I. does not act like insulin. On the 
other hand, the innpression was obtained that D.B.I, was more potent as 
a hypoglycemic agent than the sulphonylureas. As with tolbutamide, however, 
several days of treatment must elapse before nnaximal effect is demonstrated, 
and D.B.I. , like the sulphonylureas, proves more effective in patients whose 
diabetes is of short duration. 



Medical News Letter, Vol. 32, No. 4 17 



The ultimate value of maintaining normoglycemia in diabetics by sub- 
stances whose mode of action differs from that of insulin remains undecided. 
There is evidence that hyperglycemia per se is harmful if allowed to persist 
and can be responsible for the degenerative changes that occur in diabetics. 
Search for an effective nontoxic hypoglycemic agent is justifiable on these 
grounds. D. B. I— although its range of action is probably wider than that of 
tolbutamide — is unsuitable for general use because of the high incidence of 
unwanted side effects. (Hall, G.H, , Crowley, M. F. , Bloom, A., Oral 
Treatment of Diabetes - Trial of Phenethyldiguanide (D. B. I. ); Brit. Med. J. , 
5088 : 71-74, July 12, 1958) 

j}; 4: 4: :jt :{; :{{ 

Voluntary Retirement 

Retirement after 20 or more years of service has been authorized 
since 1955, and a number of Medical Department officers have been granted 
this early retirement. It is felt that the availability of early retirement is 
a distinct addition to the attractiveness of a Navy career. 

While general information on voluntary retirement appears to be 
widely distributed, letters and comments received indicate that sonne of 
the details are less widely known. The specific criteria prescribed by the 
Secretary of the Navy as meriting favorable consideration for early retire- 
ment are stated in SecNav Instruction 1811. 3A of 10 September 1955, and 
anyone thinking of making such a request should be fully acquainted with 
this instruction as well as BuPers Instruction 1811. lA of 19 July 1957. 

Among the six criteria listed is that of five years' service in grade 
for captains as well as 20 years' total service. Other of the listed criteria 
may be applicable to individual cases. Requests are considered on a basis 
of the over all needs of the Service and the merits of the individual case. 

Requests should be submitted at least three months and not more than 
six months ahead of the desired date, and the preretirement physical must 
be reported to the Chief of Naval Personnel from one to three months in 
advance. BuPers requires that officers starting a new tour of duty complete 
at least one year at the new station before voluntary retirement is effected. 

Obviously, an unexpected request for retirement creates problems 
in connection with a relief, and in some instances insufficient time has been 
allowed in which to arrange for a relief. Consequently, it is most desirable 
that BuMed be informed of prospective retirement plans as far as possible 
in advance of the prescribed three months lead time to insure that the de- 
sired retirement date can be met. 

The Bureau is in no sense urging officers to consider early retire- 
ment. This note is simply to urge those who may be thinking of early 
retirennent to become familiar with the requirements and proper procedure 
as detailed in SecNav and BuPers Instructions. (PersDiv, BuMed) 



18 Medical News Letter, Vol. 32, No. 4 



IN MEMQEIAM 

CAPT Wendell P. Blake MC USN (Ret) 25 June 1958 

CAPT George F. Blodgett MC USN 9 July 1958 

CAPT Charles J. Holeman MC USN (Ret) 21 June 1958 

CDR Charles F. McCaffrey MC USN (Ret) 25 June 1958 

CDR Talmadge Wilson MC USN (Ret) 15 June 1958 

LCDR William A. Little MC USN (Ret) 14 March 1958 

LT John A. Drawenek MSC USN (Ret) 12 June 1958 

LT James J. Kelley MSC USN (Ret) - 1 July 1958 

LTJG Richard E. Jackson MSC USN (Ret) 16 July 1958 

****** 
From the Note Book 

1. Seventeen inactive Reserve Medical Department officers attended the 
First Commandant's Representatives' Seminar held at the Bureau of Med- 
icine and Surgery, August 4-8, 1958, Proposed by the Reserve Division 
of the Bureau, the seminar's purpose was to present an over all review of 
the Naval Reserve, the Navy's training programs for undergraduate med- 
ical students, and selected phases of recruiting concerning the commission- 
ing of MD personnel. Reserve officers attending are presently on the faculty 
or teaching staffs of accredited medical schools throughout the United States. 
(TIO, BuMed) 

2. Captain C. F. Cell MC USN has assumed the position of Special Assis- 
tant for Medical and Allied Sciences at the Office of Naval Research. Prior 
to reporting to ONR, Captain Gell was Director of the Air Crew Equipment 
Laboratory; Visiting Professor, Aviation Physiology at the University of 
Pennsylvania Medical School; and Lecturer in Aviation Medicine in the 
Graduate School of Medicine at the University. (ONR) 

3. An 8 -page supplement to the National Bureau of Standards Handbooks 
dealing with radiation protection and related matters has been prepared by 
the National Committee on Radiation Protection and Measurements (NCRP). 
Entitled Maximum Permissible Radiation Exposures for Man, the supplennent 
sunnmarizes the new recommendations of the NCRP on safe limits of radia- 
tion exposure; it extends and clarifies the Preliminary Statement issued by 
the Connmittee in January 1957. The new publication introduces only nninor 
changes and is intended to be in general conformity with the philosophy ex- 
pressed in the April 1956 statements of the International Commission on 
Radiological Protection (ICRP). (NBS) 



Medical News Letter, Vol. 32, No. 4 19 



4. In a reprint personally forwarded to the Editor, Captain A.G. Bower 
MC USNR reports in an article published in Arizona Medicine, October 
1957, that "Beginning in 1948, gamma globulin was given to virtually 
every case of infectious mononucleosis admitted to his hospital. In more 
than 200 cases so treated, the result was excellent with only Z exceptions; 
one was tracheotomized in a respirator because of an infectious neuronitis; 

the other was a complicating meningoencephalitis In the average 

case of infectious mononucleosis, in which the dose of gamma globulin is 
adequately assessed as to size, it acts as specifically as antitoxin does in 
diphtheria, and if too small a dose is given, there is no harm in repeating 
it. " (See Medical News Letter, Vol. 32, No. 2, p. 7) 

5. A review of the basic studies of the physiology and chemistry of psoria- 
sis indicates that this is a hereditable disease showing a distinctive locali- 
zation pattern and one in which the specific defect now appears to be in the 
enzyme systems concerned with the protein metabolism of the epidermis. 
(Arch. Dermat. , July 1958; W.B. Shelley, M. D. , R. P. Arthur. M. D. ) 

6. A study of the occurrence of cervix cancer in an asymptomatic popula- 
tion, three quarters of whom return for repeat examinations, is presented. 
Exfoliative cytology utilizing direct cervical smears was the primary means 
of detection for 91% of the cancers found. The cytological false negative 
errors from all sources were less than 10% for a single exannination. This 
error beconnes vanishingly small with repeat exanninations since the data 
suggests that the average in situ cancer exfoliates diagnostic cells for 8 

or more years before becoming invasive. (Cancer, July - August 1958; 
J.W. Berg, M.D., G. M. Bader, M. D. ) 

7. A series of 96 bladder tumors occurring in women is reported. The 
salvage in the superficial tumors was 44. 4%, in the deep tumors 12. 1%, 
and in all cases 33.3%. In the same series, the 5-year salvage was 41% 
in the superficial tumors, 4. 7% in the deep tumors, and 28. 3% in all cases. 
The best results obtained in any group was in the group A tumors treated 
by means of interstitial implantation of radon seeds combined with electro- 
surgical resection or fulguration. (J. Urol. , July 1958; C. B. Brack, 
R.E.L. Nesbitt, Jr., H. S. Everett) 

8. The results of repairing traumatic iris prolapses by replacement of the 
prolapsed iris have proved that this mode of repair is clinically sound and 
is to be preferred in suitable cases to the traditional method of abscission. 
A special technique recommended as a standard procedure consists essen- 
tially in an intraocular reposition carried out with a spatula through an 
incision at the limbus. (Brit. J. Ophth. , July 1958, R. Stein, Israel) 



20 Medical News Letter, Vol. 32, No. 4 



9. Esophageal disorders and disease may give rise to pain that is referred 
to the anterior part of the thorax. The pain nnay be situated some distance 
from the site of the esophageal involvement and may vary considerably in 
intensity and character. The possibility of an esophageal origin must 
always be considered in any patient with unexplained anterior thoracic pain. 
(Dis. Chest, July 1958; H.J. Moersch, M.D., F. E. Donoghue, M. D. ) 

10. Strangulated diaphragmatic hernia is a serious emergency with a re- 
lative high mortality. It is suggested that a more aggressive attitude be 
taken in treating this type of hernia before it becomes strangulated, as 
surgical repair of the hernia itself is simple with a very low mortality 
rate when no strangulation is present. (J. Thoracic Surg. , July 1958; 

E. F. Skinner, M. D. et al. ) 

11. An autopsied case of pancytopenia associated with thymoma is des- 
cribed, and the published cases of this rare clinical syndrome are reviewed. 
The unusual frequency of spindle-cell thymomas associated with this syn- 
drome is discussed. (New England J. Med., 17 July 1958; J. W. Josse, 

M. D. , S.I. Zacks, M. D. ) 

:je 9}; :je 9^ ^e >}: 

Applications for Training in Civilian Institutions 

In view of the need for early connmitnients with civilian institutions 
for training programs to begin 1 July 1959, those medical officers interes- 
ted in civilian training programs in Neurological Surgery, Thoracic Surg- 
ery, Plastic Surgery, Children's Orthopedics, or the subspecialties of 
Internal Medicine, are urged to submit their requests to the Chief, Bureau 
of Medicine and Surgery prior to 15 September 1958, 

Individuals may indicate three choices of institutions in order of 
preference, where they desire the training; however, the Bureau of Med- 
icine and Surgery will make all contacts and arrangements with the insti- 
tutions for those approved by the Advisory Board, and applicants are 
cautioned not to make any personal contacts in an attennpt to secure an 
appointment or obtain a tentative acceptance fronn the institution. 

Applications from career medical officers qualified to enter these 
programs should be made by official letter to Chief, BuMed, via chain of 
command, and should include the obligated service agreement stipulated 
in BuMed Instruction 15Z0, 7B. Only a limited number of individuals will 
be sponsored in such programs in view of the existent personnel shortage. 
(ProfDiv, BuMed) 

:i!f i^ yf/i i^ il/: :l^ 



\ 



Medical News Letter, Vol. 32, No. 4 21 



Symposium on Scintiscanning 

The U. S. Naval Medical School, Bethesda, Md. , will offer a one -day 
symposium on "Advances in Nuclear Medicine" on 4 October 1958. This sym- 
posium will be on Scintiscanning and will be the first generah symposium 
on this technical clinical phase of Nuclear Medicine. 

Twelve prominent speakers have been selected and the topics will 
cover all phases of clinical applications of scintiscanning plus reviews and 
critiques of methods of detection, coUimation, shielding, and dosimetry in- 
volved in this procedure. Following the noon luncheon in the Officers' Mess, 
an open question and answer period will be held. 

Medical Corps personnel desiring to attend the symposium should 
submit written requests in compliance with BuMed Instruction 1520. 8. Such 
requests should be received in the Bureau prior to 9 September 1958 for 
consideration by the Advisory Board. If approved by the Advisory Board, 
TAD orders will be requested by the Bureau utilizing BuMed training funds. 

Commanding officers may be guided by the following priorities for 
medical officers who may desire to apply for attendance at the symposium: 

1. Chiefs of Radiological Service 

2. Radiology Residents 

3. Medical officers engaged in the clinical 
use of Radioisotopes 

A second symposium will be conducted by the U. S. Naval Medical 
School, NNMC, Bethesda, Md. , during the spring of 1959. This second 
symposium will cover Low Background Counting and the Evaluation of 
Radiation Casualties. When firm arrangements are completed, another 
article will be published giving full details. (ProfDiv, BuMed) 



iff Iff :i^ ^ )ii :(li 

Course in Occupational Medicine 

A two-day course in Occupational Medicine is being offered by the 
Postgraduate Committee of the University of Maryland School of Medicine. 
The course will be held in Chemical Hall (on the campus), Lombard and 
Green Streets, Baltimore, Md. , 16 and 23 October 1958 (a week interval 
between meeting days). The tuition is $20. 00. 

Schedule for 16 October 1958 - first day 

9:00 - 10:00 a.m. Registration - Postgraduate Committee Office 

10:00 - 12:30 Cardiac Disease in Industry 

(Panel: Cardiologist, full-time Industrial 
Physician, and Management) 



9:00 - 


10:00 a. m. 


10:00 


- 10:20 


10:25 


- 10:45 a. m 


10:50 


- 11:10 


11:15 


- 12:30 


12:30 


- 1:30 p. m. 


1:30 - 


4:00 



22 Medical News Letter, Vol. 32, No. 4 



12:30 - 1:30 p.m. Luncheon 

1:30 - 4:00 The General Practitioner in Industrial Medicine 

(Panel: Professional Educator, Member, 
Maryland Academy of General Practice; and 
"Small Industry" Physician) 

Schedule for 2 3 October 1958 - second day 

Registration - Postgraduate Cominittee Office 
Function of Governmental Groups in Occupational 
Health (Paper) 
Radiation (Paper) 

Utilization of the Abilities of Older Individuals in 
Industry (Paper) 

Medicolegal Aspects in Industrial Medicine 
Luncheon 

The Role of Doctor, Nurse, Management, and 
Industrial Hygienist in Industrial Medicine 
(Panel: Doctor, Nurse, Management, and 
Industrial Hygienist) 

Note: The audience will be given opportunity to ask questions of the panel 
members. 

Medical Corps officers of the Regular Navy and Naval Reserve on duty 
at Naval activities not too distant from Baltimore may submit an official re- 
quest for one or both days of this short course in occupational medicine to 
the Chief, Bureau of Medicine and Surgery in accordance with instructions 
contained in BuMed Instruction 1520. 8 of 6 February 1956. Requests should 
reach the Bureau not later than 10 September 1958. (OccMedDispDiv, BuMed) 

* ;[; ;}: ?;< * 5j< 

Postgraduate Short Courses for Naval Medical 
Officers - Sponsored by U. S. Army 

The following postgraduate short courses will be given during Fiscal 
Year 1959 as indicated below. Eligible officers are those who meet the 
criteria prescribed by BuMed Instruction 1520. 8 of 6 February 1956. 

Eligible and interested officers should forward requests via official 
channels, addressed to the Chief of the Bureau of Medicine and Surgery. 
Requests for attendance must be received in BuMed at least 6 weeks prior 
to commencement of the course requested. Travel and per diem orders 
chargeable against Bureau funds will be authorized those approved for 
attendance. 



Medical News Letter, Vol. 3Z, No. 4 



23 



Course 



J_rOcation 



Dates 



James C. Klmbroiigh Brooke Army Medical 3-5 Nov. 'SS 

Urological Seminar Center 



BuMed 
Quota 
5~ 



Pathology of Diseases Armed Forces Institute 8-lZ Dec. '58 10 

of Laboratory Animals of Pathology 

(ProfDiv, BuMed) 



* * * 



Board Certifications of Inactive Reserve Officers 



Amierican Board of Anesthesiology 
LT John R. Jones (MC) USNR 

American Board of Dermatology 

LTJG Femvick L. w"ktts (MC) USNR 

American Board of Internal Medicine 

LTJG David S. Masland (MC) USNR 
LTJG Stanley M. Pariser (MC) USNR 
LTJG Carl Wierum (MC) USNR 
LT William J. Williams (MC) USNR 

American Board of Obstetrics and Gynecology 
LT William E. Crisp (MC) USNR 
CDR Forrest H. Howard (MC) USNR 
LT Myles C. Morrison, Jr. (MC) USNR 

Annerican Board of Pediatrics 

LT Ralph J. Bertolin (MC) USNR 

American Board of Ps ychiatry and Neurology in Psychiatry 
L-P Charles E. Meredith (MC) USNR 

American Board of Surgery 

LT William P. Corvese (MC) USNR 
LTJG Frederick M. Davies (MC) USNR 
LCDR LeRoy F. Lundy (MC) USNR 
LT Robert D. Rector (MC) USNR 



American Board of Urology 

LCDR Henry E. Wolfe, Jr. (MC) USNR 



24 Medical News Letter, Vol. 32, No. 4 

Rec ent Research Reports 
(Continued from 18 July issue) 

Naval Dental Research Facility, NTC, Balnbridge. Md . 

1. Electrophoresis of Saliva, m. Relationship of Protein Components to 
Dental Caries, NM 75 01 26. 05, 2 June 1958. 

2. Dental Caries Susceptibility Before and After the Extraction of Teeth. 
NM 75 01 26. 03, 10 July 1958. 

Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. Studies on Steroid Excretion in Calf Urine. NM 01 02 00. 02, 04, 3 January 

1958. 

2. Adrenal and Reproductive Responses to Population Size in Mice from 
Freely Growing Populations. NM 24 01 00. 04.02, 13 January 1958. 

3. Hematological Values of Guinea Pigs. Memorandum Report 58-1, 
NM 62 04 00.03, 21 January 1958. 

4. Thermal Radiation Burns in Rabbits. VI. The Effect of the Immediate 
Application of Cold to "Flash"-Type Burns on Severity as Measured by 
Radioactive Phosphorus Uptake. NM 007 081.03.07, 21 January 1958. 

5. Normal Fecal Excretion Values for Coliforms and Enterococci. NM 52 04 
00.02.05, 27 January 1958. 

6. Studies on Mineral Metabolism in the Albino Rat. I. Occurrence of Urinary 
Calculi. NM 75 01 00.01.03, 27 January 1958. 

7. Polynucleotides II. Physical Properties of Solutions of Some Polynucleo- 
tides. NM 02 01 00. 01. 03, 3 February 1958. 

8. Physiochemical Characterization of a Compound Isolated froin Bovine 
Spinal Cord. Memorandum Report 58-2 related to NM 02 06 00, 02, 6 February 
1958. 

9. Heat Changes During the Clotting of Fibrinogen. Memorandum Report 58-3 
related to NM 02 05 00. 07, 24 February 1958. 

10. Measurement of Changes in Acetylcholine Level in Rat Brain Following 
Ammonium Ion Intoxication and Its Possible Bearing on the Problem of Hepatic 
Coma. NM 72 02 00. 01.01, 20 March 1958. 

11. Spectral Changes Accompanying Binding of Several Dyes by Polyadenylic 
Acid. Memorandum Report 58-4 related to NM 02 01 00.01, 21 March 1958. 

12. Comparison of Several Methods for Producing Solubilized Human Keratin. 
NM 71 07 00. 04. 01, 27 March 1958. 

13. Polynucleotides V: Titration and Spectrophotometric Studies upon the Inter- 
action of Synthetic Polynucleotides with Various Dyes. NM 02 01 00.01. 04, 1 
April 1958. 

14. Summaries of Research. 1 July 31 December 1957. 



Medical News Letter, Vol. 32, No. 4 25 



Naval Medical Research Unit No. 3, Cairo, Egypt 

1. Observations on Egyptian Hyalonnoia Ticks (Ixodoidea, Ixodidae). 6 Bio 
logical Notes and Differences in Identity of H. Anatolicum and its Subspecies 
Anatolicum Koch and Excavatum Koch among Russian and Other Workers. 
Identity of H. Lusitanicum Koch. NM 52 08 03. 12, December 1957. 

2. Histopathology of Cardiopulmonary Schistosomiasis, Review of Literature. 
NM 52 02 03.9, January 1958. 

Naval Medical Research Laboratory, Submarine Base, New London, Conn. 

1. Personal Inventory Barometer (PIB) I. Development of the Questionnaire. 
NM 23 02 20, Subtask No. 1, Report No. 1, 22 August 1957. 

2. Limited Field Evaluation of the Millipore Field Monitor Kit Aboard 
Submarines. NM 24 01 20,04.03, 19, March 1958. 

3. A Group Automatic Audiometer in a Hearing Conservation Program. 
Memorandum Report No. 58-3. NM 22 01 20.03,01, 24 March 1958. 

4. Proposed Specification for Audiometers. Memorandum Report No. 58-5, 
NM 22 01 20. 03. 02, 28 March 1958. 

5. Energy Integration in the Ear. Memorandum Report No. 58-6, NM 22 01 20 
.03. 03, 4 April 1958. 

Naval School of Aviation Medicine, NAS, Pensacola, Fla. 

■ ■ ■ - - - I 

1. Effect of Shouting on Blood Oxygen and Alveolar Carbon Dioxide. Report 
No. 1, Subtask No. 3, NM 12 01 11, 15 November 1957. 

2. A Note on Occupational Ratings of Security and Prestige. Report No. 5, 
Subtask No. 4, NM 16 01 11. 25 November 1957. 

3. Ballistocardiogram During Muscular Relaxation with Succinylcholine. 
Report No. 4, Subtask No. 6, NM 18 03.11, 21 January 1958. 

4. A Note Concerning "Motion Sickness" in the 2-FH-2 Hover Trainer. 
Report No. 1, Subtask No. 3, NM 17,01 11, 20 February 1958. 

5. Oxygen Toxicity in Aviation Medicine. - A Review, Report No. 2, Subtask 
No. 11, NM 12 01 11, 24 February 1958. 

6. Effect of Breathing 100% Oxygen at Atmospheric Pressure upon the Visual 
Field and Visual Acuity. Report No. 1, Subtask U, NM 12 01 11, 11 March 
1958. 

*J^ ill— J-* Orf mjj Jv 

-r- •V' ■*!> T 'r -p 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

3jc :{f! sf; :Jc :{: :{j 



26 



Medical News Letter, Vol. 32, No. 4 



DEIMTAL 




SECTIOIV 



Forty-Sixth Anniversary Greetings 

Doctor William R. Alstadt, President of the American Dental Assoc- 
iation, addressed the following letter to Rear Admiral R. W. Malone, Dental 
Corps U. S. Navy, Assistant Chief for Dentistry and Chief, Dental Division, 
Bureau of Medicine and Surgery, 

"Rear Admiral R. W. Malone (DC) USN 
Assistant Chief for Dentistry and 

Chief, Dental Division 
Bureau of Medicine and Surgery 
Navy Department 
Washington 25, D. C. 

Dear Admiral Malone: 

On August 22, 1958, the Dental Corps of the U. S. Navy will celebrate 
its 46th anniversary. In behalf of the inore than 90,000 members of the 
American Dental Association, may I extend to you and all members of 
the U.S. Navy Dental Corps our sincere congratulations upon this 
occasion. 

The American Dental Association, of which you and the members of 
the Navy Dental Corps are full members, is extremely proud of the 
splendid record that all of the officers helped to create since the begin- 
ning of your Corps on August 22, 1912. In my various capacities with 
the American Dental Association through these past years, I have been 
privileged to note in great detail the splendid professional service, ex- 
cellent morale, and the fine sense of duty that your members exhibit. 

The record of the U. S. Navy Dental Corps is one that the members 
of the American Dental Association looks to with pride, and you, as 
Chief of the Dental Division, are carrying on a splendid tradition that 
has been so well established by your eminent predecessors. 



Sincerely, 



W, R. Alstadt, D. D. S. 
President" 



Medical News Letter, Vol. 32, No. 4 27 

Navy Dental Care - FY 1958 

Dental care was provided to Navy and Marine Corps personnel during 
Fiscal Year 1958 at four hundred and seventeen Navy dental facilities ashore 
and afloat throughout the world. In addition, dental care w^as provided to 
personnel in many areas of the United States where no permanent dental 
facilities are available by dental officers attached to the Navy mobile dental 
units. Approximately eight million dental examinations, treatments, and 
operations were accormplished in all branches of dentistry except orthodon- 
tics for military personnel and their dependents. 

Fiscal Year 1958 was the first complete fiscal year in which depen- 
dents outside the continental limits of the United States and at specifically 
designated "remote areas" within the continental limits of the United States 
received dental care under the Dependents' Medical Care Act. During this 
period, some three hundred and thirty thousand dental procedures were 
accomplished for approximately ninety thousand dependents. 

:^ iflL iff iji ^ !{: 




RESERVE SECTIQIM 



Seminar for CO's of Reserve Medical Companies 

During the period 20-24 October 1958, a seminar for Commanding 
Officers or their representatives of Reserve Medical Companies will be 
presented at the Bureau of Medicine and Surgery. 

Approximately twenty Medical Corps and Medical Service Corps 
officers of medical connpanies established within the First, Third, Fourth, 
Fifth, Sixth, Eighth, and Ninth Naval Districts are expected to attend. 

The program as planned will present an over all review of the Naval 
Reserve with special emphasis on training in the Navy's Medical Depart- 
ment. Officers and departments of the Department of Defense, Chief of 
Naval Operations, Bureau of Naval Personnel, and the Bureau of Medicine 
and Surgery will highlight the seminar by presentations affording an insight 
to their functions at a departmental level. Field trips to the National Naval 
Medical Center, Armed Forces Institute of Pathology, National Institutes 
of Health, Naval Gun Factory, and Naval Diving School assure a most 
interesting and infornnative period of training for this group of selected 
officers during this period. The Reserve Division, Bureau of Medicine 
and Surgery conducts this seminar on a year to year basis. 



28 Medical News Letter, Vol. 32. No. 4 

Correspondence Course Training 

INSECT AND RODENT CONTROL - NavPers 10705-A. 1957 edition, recom- 
mended for all Medical Department personnel. 

Advances in knowledge of the life history and habits of pests, the 
Introduction of new materials in building construction, and the discovery 
of new chemical agents have been utilized in combination to broaden under- 
standing of means for controlling disease vectors. From these advances, 
it has been possible to make pest control more effective. This course 
provides MD personnel with information pertaining to insects and rodents, 
their living habits, the manner in which they spread disease, and the 
diseases with which they are associated. It includes instructions for pro- 
per methods utilized in preventing and correcting infestation. It indicates 
what poisons should be used to control various kinds of pests and the dan- 
gers involved in the use of each poison. It also advises on methods of 
handling materials to avoid dangerous results. 

The course consists of two (Z) objective type assignments and is eval- 
uated at six (6) Naval Reserve and/or nondisability retirement points. 
Naval Reserve personnel who previously completed the correspondence 
course entitled, "Insect, Pest, and Rodent Control, " NavPers 10705, will 
receive additional credit for completing this course. 

MEDICAL SERVICE IN JOINT OVERSEAS OPERATIONS - NavPers 10769. 

1957 edition, recommended for all Medical Department personnel. 

This course is designed to familiarize senior staff officers of the 
Armed Services with the general doctrines, organization, and practices 
of the joint medical services of the Army, Navy, and Air Force, and 
with problems involved in the employment of these medical services in 
joint overseas' operations. The course material concentrates on the 
over all mission of military medical service and includes a brief con- 
sideration of each of the medical services individually. The technique 
of employment of joint medical service is discussed from the aspects 
of the estimate, plan, and operation. Throughout the text, the use of 
technical medical terminology and doctrine has been avoided. Discus- 
sions concerning the unilateral employment of each medical service 
provide background information and delineate certain responsibilities. 

The course consists of two (2) objective type assignments and is eval- 
uated at six (6) Naval Reserve promotion and/or nondisability retirement 
points. 

Applications for the above courses are submitted on NavPers 992 
(Rev, 1-57) appropriately completed and forwarded via your Commandant 
to the Commanding Officer, U. S. Naval Medical School, National Naval 
Medical Center, Bethesda 14, Md. 



Medical News Letter, Vol. 32, No. 4 29 



Multiple Enrollment. Medical Department personnel may be enrolled 
in more than one MD correspondence course at one time. 

^ :^ :^ ^ :^ ^ 

Catalog of Correspondence Courses 

A printed booklet listing all the Medical Department correspondence 
courses available to inactive Reservists may be obtained at no cost by letter 
or postcard addressed to: 

Commanding Officer 
U. S. Naval Medical School 
National Naval Medical Center 
Bethesda 14, Md. 

In addition to providing a biographical sumnnary on each of the courses 
offered, general information concerning eligibility, application instructions, 
enrollment, study material, requirements for completion and recording of 
pronnotion point credits is furnished. This informative catalog is a handy 
convenient size that is an important reference to the Reservist participating 
in correspondence course training. (Naval Medical School, NNMC) 

3^ >^ :(c ^ :^ 3^ 



AVIATION MEDICINE DIVISION 




Aeronautical Adaptability 

The dictionary indicates that the word "aeronautic ally" originates 
from the Latin "aer" meaning air, and the Latin "nauticus" meaning per- 
taining to a seaman, sailor, or ship. From the dictionary standpoint, 
"adapt" is a transitive verb from the Latin "ad" plus "aptare" to fit, from 
"aptus", fit. Synonyms of adapt are: adjust, accommodate, conform, recon- 
cile. It specifically implies modification to mieet new conditions and connotes 
pliability or readiness and implies bringing into as exact or close a corres- 
pondence as exists between parts of a mechanism, but suggests more tact 
or more ingenuity. It implies a giving or yielding in to the requirements 



30 Medical News Letter, Vol, 32, No. 4 



or demands. It implies a bringing into accordance with a pattern, example, 
or principle. It implies the demonstration to one's own or another's satis- 
faction, o£ the consistency or congruity of things that are, or seem, to be 
incompatible. "Adaptability" is the noun form corresponding to the verb 
"adapt. " Therefore, aeronautical adaptability literally means a "seaman, 
sailor, or ship" which, or who, is "suitable, fit, or adjusted to the air. " 

A definition for aeronautical adaptability used by a senior flight sur- 
geon previously attached to the Bureau of Medicine and Surgery was: "Aero- 
nautical adaptability is a nnental adjustment which is made in the transition 
from the normal terrestrial locomotion of man to the abnormal conditions 
of aerial flight. On the one hand, the normal elements of anxiety and fear 
tend to deter, while motivation based upon confidence in one's ability to 
control the physical forces which sustain flight, induces man to fly. " 

Relative to the Air Force attitude toward the subject, there is infor- 
mation in the Air Force Flight Surgeon's Manual (AF Manual l60-5), page 
185, as follows: (Quote) "Refusal to Fly. There is the flyer who after one or 
or two missions — even before reaching combat — voluntarily and apparently 
on a very conscious level, refuses to fly. The conscious motivation in such 
cases may be more apparent than real because the mechanism of displace- 
ment operates in this instance. Such individuals constitute a sonaewhat 
complex problem. The flight surgeon's function in this particular case is 
to determine the medical aspects of the individual's refusal to fly. Each 
case requires careful consideration and evaluation. Psychiatrically, these 
men demonstrate evidence of a low anxiety threshold, so that threat to self- 
preservation, along with their poorly developed personality structure, 
forces them to take the only steps which they know to allay this anxiety 
directly. Disposition of individuals who refuse to fly is extremiely impor- 
tant, especially from the standpoint of group morale and motivation. It is 
deleterious to motivation and morale to excuse through medical channels 
an individual who has failed to perform his duties. Extreme care should be 
taken in excusing medically an individual who refuses to fly, and psychia- 
tric evaluation should be obtained if it is deemed necessary. From a mil- 
itary administrative point of view, such cases are ordinarily considered 
not unconsciously motivated' and, therefore, become an administrative prob- 
lem. " (Unquote) 

The Air Force policy has been discussed with a representative of the 
Air Force Surgeon General's office. Their policy seems to be a firm ap- 
proach and is as follows: If an individual submits a request to discontinue 
flying, he is examined by the flight surgeon. It is felt that the flight surgeon's 
responsibility is not to make an administrative decision, but to determine "is 
he sick" or "is he not sick, " "does he have a psychoneurosis" or "does he 
not have a psychoneurosis. " If he is truly sick, and has a definite diagnos- 
able emotional problem or psychoneurosis, he is then admitted to the sick 
list and handled via medical channels. If he is not one who actually needs 



Medical News Letter, Vol. 32, No. 4 31 



medical care, he then is handled administratively. The pilots are placed 
in three categories by length of service since designation; i.e. , 
(1) those with less than 10 years' service since designation 
(Z) those with more than 10, but less than 15 years' service since 
designation 

(3) those having completed more than 15 years' service since desig- 
nation. 

If an individual in the first group (less than 10 years' service since 
designation) submits a request to discontinue flying,, in general, it is not 
looked on favorably as a lot of money has been spent on him and the Air 
Force has a big investment in him and he is obligated to perform. His 
case goes to a board and a decision is made. Usually, the decision is that 
he must fly or he is considered to be not of good caliber and his commission 
is revoked if a Reserve officer. If a Regular officer, he reverts to his per- 
manent rank. Exceptions are made in rare instances when the officer is 
especially adept at some line of endeavor and his services are especially 
desired. In general, pilots with less than 10 years' service cannot "turn 
in their wings. " If an individual in the second group (with more than 10 
years' but less than 15 years' service since designation) submits a request 
to discontinue flying, a board considers his case and his request may or may 
not be approved. If an individual in the third group (more than 15 years' 
service since designation) submits a request for discontinuing flying, his 
request under usual circunn stances will be granted. This policy was for- 
mulated and crystallized during the Korean conflict when it was brought out 
(Air Force) that it is not the medical departnnent' s responsibility to make 
a determination regarding the flight status of well aviators — the problemi is 
administrative. It was determined that there are combat people trained in 
different lines of endeavor — i.e., infantrymen, gunners, nnedics, supply 
personnel, comrnunications, specialists, flyers, etcetera, — and all nnust 
produce when needed and cannot be permitted to fail to produce just because 
of personal desires. They classify fear of flying into two categories: 

(1) Fear of flying with emotional disturbances, psychoneurosis diag- 
nosable and labeled. These are medical cases and are medically treated 
and processed. 

(2) Fear of flying with no emotional or psychoneurotic basis. They are 
boarded and possibly separated fronn service and it is a blot on their re- 
cord. 

With reference to naval aviators, the question has been posed, "If a 
pilot decides that he just doesn't want to fly any more, is he considered to 
be not aeronautically adapted?" Naval aviation personnel "who just don't 
want to fly any more" should submit a request to that effect to the Chief of 
Naval Personnel in accordance with BuPers Instruction l6ll. 6, paragraph 
4.c.(7), which states: (Quote) "Naval aviators who desire to terminate their 
flight status shall be immediately suspended from further flight duties by the 



32 Medical News Letter, Vol. 32, No. 4 



commanding officer and shall be directed to submit an official request to 
the Chief of Naval Personnel via the chain of command, and to the Chief 
of Naval Operations (Op-54). A report on the case by a flight surgeon shall 
accompany the request, " (Unquote) 

The examining flight surgeon in any specific case may be of the opinion 
that the examinee is aeronautic ally adapted or is not aeronautic ally adapted 
based on the "picture as a whole. " If the flight surgeon were expected to 
automatically say "not aeronautic ally adapted, " there would be no need for 
flight surgeon evaluation and the decision could be made by administrative 
personnel. The decision should be arrived at on a medical basis consider- 
ing background and all related factors and circumstances, and the flight 
surgeon's conclusion should be on medical grounds instead of an adminis- 
trative basis. To answer the above-posed question specifically, the answer 
is "No"; if a pilot decides that he just doesn't want to fly any more, he is not 
necessarily considered to be "not aeronautically adapted. " He may be either 
aeronautically adapted or not aeronautically adapted and it is the flight sur- 
geon's responsibility to make such a determination in each case. 

7j! ^ :li: ^ y^ ij: 

Aircraft Accident Reporting - New Forre] 

New aircraft accident, incident, and ground accident reporting pro- 
cedures became effective on 1 July 1958 with the publication of OpNav 
Instruction 3750. 6C. Each flight surgeon should have received a copy of 
this instruction from the Naval Aviation Safety Center during July. The fol- 
lowing is quoted from the Safety Center's covering letter: 

"Attached is a copy of OpNav Instruction 3750, 6C, Navy Aircraft 
Accident, Incident, and Groiind Accident Reporting Procedures, which 
became effective 1 July 1958 replacing OpNav Instruction 3750. 6B. 
Unfortunately, there are not enough copies available for each Naval 
Flight Surgeon to have a personal copy. This copy is intended as a per- 
manent part of the medical departn^ent literature. In order to assure 
its availability to the unit's medical department, it is requested that upon 
your detachment from your present unit, you turn it over to your relief. 

This instruction has undergone almost complete revision and it will 
not be possible for you to fulfill your obligations as a member of your 
unit's aircraft accident board without the information contained therein. 
You will find detailed instructions in Section H regarding the preparation 
of the new Medical Officer's Report of Aircraft Accident, Incident, or 
Ground Accident, OpNav Form 3750-8, 8A, 8B, 8C, 8D, and 8E (Rev- 
5-58). Although this forin will not be available for Z to 3 months, the 
majority of information contained in this section will be of value in the 
preparation of the present MOR, OpNav Form 3750-8 (Rev-2-54)" 



Medical News Letter, Vol. 3Z, No. 4 33 



A speedletter, dated 30 June 1958, was sent to all major commands 
with information that these new Medical Officer's Report Forms would not 
be available for 2 to 3 tnonths. 

It is desired that all flight surgeons study the Medical Officer's 
Report section of the new OpNav Instruction in preparation for use of the new 
form. 

j1<; 4= * * ^ >{! 

Naval Aviator - Flight Surgeon 

For a number of years, the Chief of Naval Operations has permitted 
the Chief of the Bureau of Medicine and Surgery to nominate a limited 
number of qualified flight surgeons for training as naval aviators. Those 
flight surgeons who successfully complete the training syllabus are desig- 
nated naval aviators and are ordered to duty as such in the actual control of 
aircraft. This is in addition to duties for which they are assigned as a med- 
ical officer. 

In the near future, there will exist vacancies for several naval aviator- 
flight surgeons and it is desired that deserving, well motivated, 35 years of 
age or younger, and physically qualified Regular U.S. Navy flight surgeons 
fill these vacancies. Successful candidates shall be assigned to test pilot 
billets connected with the human engineering phases of the Navy's develop- 
mental programs, as well as other related operational and administrative 
assignments. 

Those active duty flight surgeons, U. S. Navy or U, S, Navy Reserve 
who will transfer to the Regular Navy, who are particularly desirous of 
becoming naval aviators are invited to apply for flight training by letter 
request to the Chief, Bureau of Medicine and Surgery, Aviation Medicine 
Operations Division, Navy Department, Washington 25, D, C. Those 
flight surgeons who complete the training and are designated as naval avia- 
tors shall incur a service obligation of 3-1/2 years following date of desig- 
nation. Additional information concerning time and duration of training and 
other questions will be answered to parties requesting same, 

;j^ s{: >!e * ;j! * 

Occupational Health Hazards 

Industrial preventive medicine is an important facet of aviation med- 
icine that is occasionally slighted in favor of the more glamorous aspects 
of flight surgery. Groixnd crew personnel are particularly exposed to many 
occupational health hazards that are foreign to flight personnel. With this 
in mind, the following excerpts from Occupational Health Reports to the 



34 Medical Ne-^s Letter, Vol. 32, No. 4 



Bureau are reprinted. An alert flight surgeon with knowledge of potential 
occupational health hazards can prevent the occurrence of serious or even 
fatal situations. 

1. Ground check of a J-57 engine with after burner was done along 
the seawall about 75 feet from the boathouse and 300 feet from a hangar. 
Sound levels were in excess of 140 db inside the boathouse and approx- 
imately 128 db at the end of the hangar. A new location in an isolated area 
has been prepared and is in use for turn-up of aircraft engines with after- 
burner. Acceptable sound attenuating structures or devices have not 
been obtained to permit turn-up in populated areas. 

2. An old engine test cell used for reciprocating engines was mod- 
ified to handle J-65 jet engines. The effectiveness of acoustical atten- 
uation achieved by the noise silencing system was tested using the Air- 
craft Industries Association's "Unifornn Practices for the Measurement 
of Aircraft Noise. " In this nnethod, one set of measurements is taken 
inside the test cell to the rear of the engine outside the stack exhaust 
stream. Inside the test cell, the microphone is positioned two engine 
nozzle exit diameters off the exit centerline and two such diameters 
downstream. Several other intermediate positions are also specified in 
this scheme. The results indicated that the degree of attenuation is much 
less than that of test cells specifically built for jet engines. Detailed 
data is available which may serve as a guide to other naval activities 

who nnay wish to evaluate their test cell silencing effectiveness. 

3. A survey of noise exposure from ground-check operations of A4D 
aircraft equipped with the J-65 engine and with a deflecting shield placed 
approximately 50 feet from the exhaust and revealed maximum noise 
pressure levels (NPL) of 140 db just off the port side of the tail end at 
full power; at a distance of 100 feet from port side as well as 100 feet 
from the starboard side of the tail end — 120 db; at a distance of 80 feet 
on line from the center of the deflecting shield — 120 db; at a distance 

of 220 feet from the tail end — 110 db; at a distance of 150 feet on line 
from the nose of the plane — 105 db. With only the starter on and at a 
distance of 30 feet from the center of the plane, readings of 120 db were 
obtained. NPL of 132 db vvere obtained while testing the emergency gen- 
erator. Men servicing the aircraft were found wearing the approved 
MSA Noisefoe ear cushions and some were found wearing ear plugs in 
addition to the ear cushions. The recommended use of ear-defenders in 
addition to the over-the-ear protectors was emphasized. Inasmuch as 
the present conditions constitute a health hazard, a request was made to 
the Bureau of Aeronautics for permission to purchase jet engine noise 
suppressors so as to eliminate the high noise levels among ground-check 
personnel and also among personnel working in the surrounding areas 
and buildings. 



Medical News Letter, Vol. 32, No. 4 35 



4. Noise level measurements (101) were made aboard an aircraft 
carrier vinder repair. Approximately 82% of the einployees were ex- 
posed to noise levels between SO and 99 db during the working day; 
about 10% were exposed to levels above 100 db. The skills involved 
were welders, shipfitters, electricians, electronics mechanics, mach- 
inists, pipefitters, chippers, and riveters, 

5. Three paint removing connpounds, Clarco Stripper , Turco #4377B, 
and Harco #95-1 -A, used for stripping paint from aircraft, were eval- 
uated for relative degree of toxicity. Chamber tests run under simula- 
ted conditions in the laboratory showed the following: 

Concentration of Alkali 
Material in the Air (as ppmi of NH;^ ) pH 

Clarco Stripper 470 11.5 

Turco #4377B 610 12. 1 

Harco #95-l-A 1360 12.2 

Field tests taken during actual use of paint rennoving connpounds on air- 
craft gave the sanne relative degree of atmospheric contamination as 
found in the laboratory. Harco#95-l-A creates the most health hazar- 
dous conditions and should be replaced by a less toxic stripper unless 
the work space is equipped with adequate exhaust ventilation. 

6. In the repair of Radomes, it is necessary to strip the outside 
rubberized film. The specification for the job calls for use of methyl- 
isobutyl -ketone without detailing the nnethod of application. During a 
routine shop visit, it was noted that a strong ketone odor was emanating 
from one corner. In that location, it was found that large Radomes 
were placed on a pallet in front of a large side-draft hood; the Radomes 
were each wrapped with a cloth and buckets of solvent were then poured 
over them. A small portion of the solvent was absorbed by the cloth and 
was active in removing the rubber film, but the bulk of the solvent just 
ran down the sides and into the deck drain leading to the storm sewer. 
The pallet and the deck around it were slippery with a rubber jelly. Test 
of the air contamination made with Davis Vapotester Model M-6 revealed 
methyl-isobutyl-ketone vapor concentration near the operator as varying 
from 200 to 500 ppm, well in excess of the threshold limit value of 100 ppm. 
Investigation showed that the side -draft hood was not functioning. The 
over all solvent consumption rate for this operation was 750 gallons per 
month. It was pointed out to the shop supervisor that several serious 
hazards were being created: 

a. A health hazard due to operator's exposure to solvent vapors 

b. A fire and explosion hazard due to run-off of a flammable 
liquid into the deck drain 



36 Medical News Letter, Vol. 3Z, No. 4 



c. A safety hazard due to slippery footing. 

At a cost of $1 per gallon for the solvent, $500 per month was being 
literally poured down the drain. Recommendations included modifying 
the operating procedures by first soaking the cloth to the Radomes, 
placing a catch-pan under the pallet, and repair of the ventilation system, 

7. A proposed method for reclaiming contaminated cellulube hydrau- 
lic fluid includes a washing operation followed by heating to about 85° C. 
and agitation with air to remove the last traces of moisture. Because 
of the presence of aryl phosphates in this type of hydraulic fluid, it v»as 
felt that an evaluation of the respiratory hazard should be made. Tests 
conducted during a pilot-plant operation in an indoor location indicated 
leas than 0. 3 ppm of tricresyl phosphate in areas of maximunn possible 
contamination. The concentration during full-scale operation will prob- 
ably be less because the operation will be conducted outdoors. Because 
this value is well below the recommended safe limit of 1. ppm and 
exposure periods will be brief, no respiratory protection appears to be 
necessary. Exposed workers will be instructed in the procedures re- 
quired to prevent skin absorption. 

8. An employee who entered an elevator sump tank aboard a carrier 
collapsed within a few minutes and was removed almost immediately by 
two employees who happened to notice his plight. He recovered rapidly 
with no residual effects other than a feeling of shakiness and a slight 
difficulty in breathing. The tank was not tagged as gas -free, but the 
employee felt that it v;^as safe for entry because he was under the false 
impression that welding had been performed in the tank the night before. 
On investigation, it was found that the ship's force had used nitrogen to 
remove moisture from the hydraulic system. The amount of oxygen 
present in the tank at the time of entry could not be determined since 
the tank was blown out with air before tests could be made. Steps are 
being taken to stress the importance of complying with shipyard instruc- 
tions which prohibit entry into tanks that are not tagged with a valid gas- 
free tag, 

9. The presence of contaminants in liquid oxygen (I-OX) supplied to 
this and other Southern California stations was tentatively traced to 
pollutants in the air used for JJDX production. It was recommended that 
better filtration of the air be performed prior to its liquifaction and that 
Norite-C carbon filters in 6 to 12 mesh size be used for the purpose as 
they have been found extremely efficient for this type of filtration. 
(Derived from Occupations Health Reports, Jan, 1958 through Mar. 1958) 

>[:>[; ^e sf! ^ s|j 



Medical News Letter, Vol. 32, No. 4 37 



Postgraduate Short Courses in Aviation Medicine 
to be Conducted During the Fall 1958 at the 
Ohio State University and U. C.L. A. 

OHIO STATE - The Ohio State University announces the Fifth Annual Post- 
graduate Course in Aviation Medicine to be held at the University in Colum- 
bus, Ohio, 8-lZ September 1958. This interesting and informative course 
is presented to physicians and workers in the allied sciences with interests 
in the exciting fields of aviation and space medicine. Major areas considered 
are physiology of flight, clinical pathology, aviation accidents, medical eval- 
uations of air crews, and space medicine. Included in the tuition fees will 
be a field trip to Wright Air Development Center, Interested individuals 
should make all inquiries and applications to: 

Dr. William F. Ashe, Chairman 
Department of Preventive Medicine 
The Ohio State University 
Columbus 10, Ohio 

U.C, Li. A. - The University of California at Los Angeles announces the 
Fourth Annual Symposium in Aviation Medicine to be held 22-24 October 
1958 at the Miramar Hotel, Santa Monica, Calif. A rather comprehensive 
program covering future jet aircraft transports, space medicine, low 
altitude -low speed flying, and flight safety has been scheduled, A field trip 
to one of the nation's leading aircraft manufacturers should prove to be of 
interest. The range of discussion covers military, commercial, and pri- 
vate flying aspects of the above categories. Requests for information 
and/or applications for this symposium should be made to: 

Thomas H. Sternberg, M. D. 

Assistant Dean for Postgraduate 
Medical Education 

University of California Medical Center 

Los Angeles 24, Calif. 

Telephone: Los Angeles GRanite 8-9711 or 
BRadshaw 2-8911, ext. 7114 
Interested and eligible officers within the local areas may request 
authorization orders with the Bureau of Medicine and Surgery paying tuition 
fees. A very limited number of requesting officers not locally situated will 
be given per diern orders to these courses. Those interested officers who 
are eligible in accordance with BuMed Instruction 1520. 8 of 6 February 1956, 
should forward requests for attendance via channels to the Chief, Bureau of 
Medicine and Surgery. These requests must be received in this Bureau at 
least six weeks prior to commencement of the course requested. Travel 
and per diem orders chargeable against Bureau funds will be authorized 
to those approved for attendance. 



38 Medical News Letter, Vol. 32, No. 4 



"G" and "U" 



How about a little refresher on g's? As you know, the onset of "grey- 
out" can be noted by the average observer at 3-4 g's, vvhile he "blacks out" 
on the average of 4-5 g's. Anything that can be done to raise the vascular 
(blood vessel) pressure in his eyes will increase his g tolerance — g suits 
can raise the level 2 g's above his nonprotected tolerance. The prone posi- 
tion shortens the heart-to-eye level distance about one-half and increases 
the tolerance to about IZ g's. 

Forces of 6 g's will black out practically every upright observer 
unless he is wearing a good g suit. Turns of the following radii will each 
produce 6 g's. 

250 m. p. h 686 ft. 

500 m. p. h. Z> 740 ft. 

750 m. p. h. 6,170 ft. 

1000 m. p. h 1 1, 132 ft. 

1500 m. p. h .25, 074 ft. 

2000 m. p. h 44, 530 ft. 

At a speed of 2000 m. p. h. , the pilot could not turn a circle smaller 
than 18 miles in diameter unless wearing a good protective suit or assum- 
ing a position other than upright without being blacked out all the way around 
the turn. 

Head-to-foot forces of inertia can be impaired by mechanical factors, 
such as large varicose veins, hernia, or hemorrhoids, and therefore, con- 
traindicate exposure to acceleration. In the case of negative acceleration, 
a congenital or acquired defect of the skull is an absolute contraindication 
because the resulting failure of body counter-pressure might permit disas- 
trous bulging of the cranial contents. 

Anything that reduces blood pressure will also reduce tolerance to 
positive acceleration. Some factors could be heat, relaxation, prolonged 
bed rest, disease, or fatigue. On the other hand, factors that increase the 
blood pressure will increase tolerance. Normally, there is a higher tol- 
erance to g's during flight than when just seated in the upright position. 
This is ascribed to the higher blood pressure and the nervous and nnuscular 
tension while flying. Cold, anxiety, mental or physical stress will usually 
increase tolerance. 

It is interesting to note that a low blood sugar, hypoxia, or alcohol 
ingestion carried to the point of blood pressure reduction, diminishes 
tolerance; but, on the other hand, in their early stages of excitation, these 
agents will increase tolerance to gravitational stress. 

Bear in mind that while recovery from blackout occurs a few seconds 
after acceleration decreases, it takes much longer (20-30 seconds) to 
recover from unconsciousness. This thin margin separating blackout from 
unconsciousness can be dangerous. Visual symptoms may be accompanied 



Medical News Letter, Vol. 32, No. 4 39 



by poor judgment and deficient performance; the danger of allowing these 
symptoms to occur should be obvious. Don't forget that being in good 
physical condition helps a lot. If the pilot increases his muscular tension 
and "fights" the acceleration by using the M-1 maneuver, he may be able 
to raise his tolerance to 7 or more g's. 

Do not expose yourselves to negative accelerations in excess of 2-3 g's. 
If it is unavoidable, relax — do not strain. Straining will aggravate the symp- 
toms of fullness or throbbing pain in the head or eyes, "blood shot" eyes, 
and a nervous reflex which slows down the heart and may cause failure of 
circulation through the brain. Higher accelerations of 3-4 negative g's will 
lead to intense pain, severe nose bleeds, and bleeding into the sinuses, 
(Captain R.G. //itwer MC USN, Marine Corps Air Station, Quantico, Va. ) 

^< ^ ^ ;!c :[c ;}; 

Hypoxia - Hyperventilation or CO2? 

The conclusion is drawn that the most common symptom of hypoxia 
is hyperventilation which would explain the similarity between the two. 

The best way to rule out hypoxia is to inspect the oxygen equipment. 
If there is no evidence of malfunction, hypoxia can be eliminated in most 
instances. It must be appreciated that insignificant mask leads at ground 
level may become quite significant at altitude. 

If a subject is experienceing symptonns, it is recommended that he 
set the oxygen regulator on "ennergency, " or pressure setting, depending 
upon the regulator. At the samie time, he should: (1) check his oxygen 
equipmient, (2) begin to descend to below 15, 000 feet, and (3) breathe at a 
normal rate and depth of respiration for one to two minutes. K symptoms 
do not improve significantly, the regulator should be returned to its origi- 
nal setting and the automix turned to 100% oxygen and breathing continued 
at a normal rate for 15-20 minutes. Explanations for these reoommenda- 
tions are: 

(1) Switching over to an emergency or pressure setting will by-pass 
a ruptured diaphragm in the regulator or probably reveal its presence, 
or compensate for a mask leak. 

(2) Descending below 15,000 feet increases the time of useful con- 
sciousness, 

(3) Breathing at a nornnal rate and depth aids in consciously control- 
ling the respiration; improvemient should rapidly result. If these pro- 
cedures have not improved the symptoms, 10 0% oxygen should be in- 
haled at a nornnal pressure to avoid rapid depletion of the aircraft supply. 

The final recomn:>endation of breathing 100% oxygen for 15 minutes is 
made because recent evidence has shown that carbon monoxide poisoning is 
a form of anennic hypoxia. If toxic concentrations were present, it would 

4U. S. aoVERNMENT PRtNTlMC OFFICE ; 19^ O - 48U96 



40 



Medical News Letter, Vol. 32, No, 4 



take at least 15 to 20 minutes of breathing 100% oxygen to achieve de sat- 
uration and improvement of symptoms. 

If pilots were able to carry out the above recommendations in the 
presence of hypoxia, hyperventilation, or carbon monoxide poisoning, 
although they may not be immediately aware of the source of their difficulty, 
it would constitute the proper corrective action. (Captain H, H. Wayne 
USAF (MC): Journal of Aviation Medicine, Vol. 29 . No, 4. pp. , 307-315, 
April 1958) 

^ s^ s{<z :l^ ^i itp 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses. 

****** 



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